Written by Christine Foote-Lucero, Diana Faugno, & Kathy
BellCourtesy of the Academy of Forensic Nursing
NONFATAL STRANGULATION OF CHILDREN is often under-estimated,
under-reported, and under-researched. This article will review pediatric head
and neck anatomy that impacts risks related to strangulation; how child victims
of strangulation commonly present; common exam findings; and any recommendations
for the clinical evaluation of children.
Strangulation is defined as external
pressure applied to the neck that compresses the internal blood vessels and/or airway
(Faugno et al 2013). Significant trauma can occur as a result of this lack of
blood flow to the brain or damage to the vessels or structures of the neck and
airway. Most often, there are no outward, external signs.
Choking is different than
strangulation. Choking is the blocking of a respiratory passage, such as with a
grape or hotdog, preventing oxygen getting to the lungs. With complete
occlusion, the person cannot speak, talk, or breathe. Persons that are choking
will often clutch their throat or point to their throat and display panic.
Children may be strangled when
caregivers lose control, as part of physical and/or sexual assault, or as a way
of demonstrating ultimate power and control over the child (Training Institute on Strangulation Prevention 2019).
Mechanism for pediatric strangulation can be different than the typical and
common mechanism of manual strangulation that we see in adults. While it may be
manual (including chokehold), it is also easier to lift children off the ground
with their clothing, thus creating a ligature strangulation, which increases
pressure and compression on neck.
Any child can be strangled, but nonverbal (less than three years old) and developmentally delayed children can certainly present challenges for law enforcement and health-care professionals as it may be more difficult to obtain an accurate history.
Any child can be strangled, but nonverbal (less than three
years old) and developmentally delayed children can certainly present
challenges for law enforcement and health-care professionals as it may be more
difficult to obtain an accurate history. In addition, cognitive and
developmental differences may make it difficult for a child to effectively
describe the strangulation event. Children are most frequently strangled by the
people they love and trust, and these perpetrators are more commonly female. As
a result, children might be hesitant to disclose details of their assault if
they feel they might cause trouble for a caregiver or loved one, especially
when being questioned by law enforcement or health-care professionals (Baldwin-Johnson
& Wiese 2015).
Pediatric patients have distinct differences in their
anatomical structures when compared to adults. A child’s airway is smaller and
therefore easier to occlude than an adult. Even relatively minor changes, such
as neck flexion or mild swelling can completely occlude a child’s airway (Adewale 2009). Children also have a larger tongue
size proportionately, and a narrower epiglottis that is softer and more
horizontal until about the age of four to five years old (Adewale 2009). In
addition, the muscle and ligament development in the neck is significantly less
than that of adults and infants, and toddlers have a proportionally larger head
and occiput relative to body size (Jain et al. 2001). Pediatric patients also
have smaller nasal apertures, which can become easily obstructed by secretions,
edema, or blood.
While there is no literature that discusses the implications
of these anatomical differences during a strangulation assault, in general, the
medical provider can infer that the pediatric airway is simply more susceptible
to compromise. While research with children is limited, children can be
presumed at greater risk of life-threatening injuries if strangled due to the
variation in anatomy and physiology compared to adults. Pressures required to
occlude blood and/or air passages are also likely less than in adults.
Typical symptoms reported by children include voice changes, sore throat or neck pain, difficulty breathing, and problems swallowing.
Typical symptoms reported by children include voice changes,
sore throat or neck pain, difficulty breathing, and problems swallowing. Older
children may report urinary and/or fecal incontinence. Children may report
dizziness, chest pain, or a loss or near-loss of consciousness (Training
Institute on Strangulation Prevention 2019). Be alert that a child may describe
their symptoms in ways that are very different from an adult but are
developmentally appropriate, such as “I talked like a duck,” “I saw sparkles in
my eyes,” or “I fell asleep.” Some children may be able to articulate that they
thought they were going to die.
Typical signs that may be assessed by a health-care provider
evaluating the child can include petechiae of neck, face, or conjunctivae; bruising
of neck, potentially patterned, from fingers or thumbs, ligatures, or clothing;
defensive scratch marks on neck; abrasion patterns from jewelry or clothing on
the neck; or other findings such as vision changes, oral injuries, or respiratory
distress (Training Institute on Strangulation Prevention 2019).
“Strangled children and adolescents are at risk for serious
and life-threatening injuries,” said Dr. Bill Smock, police surgeon for
Louisville Police Department in a personal communication. “Based upon the
medical literature, although rare, this group of patients is at risk for
vertebral and carotid artery dissections, thrombosis of the carotid and
vertebral arteries, stroke, and anoxic brain injuries. Fractures of the hyoid
bone and the laryngeal cartilages occurs less frequently than in adults due to
the flexibility of the structures. Vertebral artery dissections are more common
in children than carotid artery injuries. Children, like adults, with
undiagnosed vascular injuries are at risk for stoke days or weeks post
incident. Documented symptoms of an impending or developing stroke from a
vascular injury include: neck pain, headache, vomiting, facial paralysis,
aphasia, ataxia, nystagmus, hemiparesis, syncope and vertigo.”
There is no conclusive evidence to support routine imaging in
pediatrics at this time. However, “based upon a review of the radiological
literature, the gadolinium enhanced MRI/MRA is the most sensitive procedure for
the detection of vascular injuries in the carotid and vertebral arteries,”
continued Smock. “Radiographic studies without the ability to visualize the
arterial lumen, i.e. non-contrast CT and Doppler ultrasound, have a high false-negative
rate and can miss intra-vascular injuries, especially in the proximal internal
carotid and vertebral arteries. The recommendations that are being considered
are MRI/MRA with gadolinium and CT with angiography (CTA).”
Upon “a review of the pediatric medical literature, the
gadolinium-enhanced MRI/MRA is the most sensitive imaging study available. The
CT with angiography (CTA) should also be considered if an MRI/MRA is not
available within a reasonable amount to time,” concluded Smock.
The child’s physician will determine the need for imaging and
must consider the benefits and risks of various options. Physicians may also
consider a skeletal survey for children under five years of age.
A medical forensic examination with a specially trained
forensic nurse should also be included. A complete and thorough evaluation
should occur that includes a history for diagnosis and treatment; a full head-to-toe
examination; a thorough head, eyes, ears, nose, and throat (HEENT) examination
with assessment of cranial nerves, which will also determine if there are
visual or auditory changes; a detailed intraoral assessment; photography and
documentation of all injury findings; evaluation of the cardinal gazes; and a
full set of vital signs to include pediatric Glascow Coma Score (GCS).
The forensic nurse should also check for ataxia, limb
weakness, or other peripheral neurological signs such as restlessness,
confusion, or irritability. The forensic nurse may determine there is
evidentiary value in specimen collections, which many include swabs of the
neck, fingernails, and a reference (buccal).
Discharge instructions should include thorough
parent/guardian teaching, including a low threshold to return for medical care,
which includes, but is not limited to, neck swelling, coughing up blood,
weakness/tingling, lethargy, new or worsening headache, drooling, voice
changes, and/or seizures. If the patient is not admitted, a follow-up visit
should be scheduled for 24 hours after discharge. Ice packs for neck pain and
popsicles for throat pain may also be including in the discharge teaching.
Brian is a six-year-old boy who reports to school on Tuesday.
The teacher notes bruises on the child’s face. She asks him what happened. The
boy responds that his dad makes him talk like a duck when he is not good and
that his neck is hurting. The teacher recognizes the concerns and suspicions
for strangulation and knows that teachers are mandatory reporters. Child protective
services and law enforcement are notified.
The child is brought to the child advocacy center for a
forensic interview and a medical/forensic examination. Swabs are collected and
Parents are ultimately charged with child abuse and the child
is placed with grandparents. Parents are currently serving jail time. At last
report, the child appears to be happy and well-adjusted with his grandparents.
In summary, strangulation does occur in pediatrics. While signs
and symptoms are similar to adults that have been strangled, the reported
symptoms from the child may not be as clearly described due to the cognitive
and developmental differences in pediatric populations.
“Children and adolescents who are strangled, either
accidentally or intentionally, are at risk for internal injuries including
intra-vascular damage,” stated Smock. “Damage to structures in the neck,
including arterial dissections, can occur even without visible external
injuries. Arterial dissections are associated with significant morbidity and
mortality. The undiagnosed carotid or vertebral artery dissection can result in
embolic strokes, vessel thrombosis, brain damage and death.”
Strangulation may be a component of a larger abuse picture. One
must consider that in 2020, Covid-19 had an impact on individuals seeking
treatment. This means that children experiencing strangulation and abuse might
not be identified due to the isolation caused by homeschooling, as well as fear
of virus exposure if brought to a hospital. Staff and program education is key
in recognizing this potentially lethal form of abuse for children.
About the Authors
Christine Foote-Lucero MSN, RN, CEN,
SANE-A, SANE-P has been a licensed Registered Nurse in Colorado for 18 years,
with a focus on critical care. She received a Bachelors of Science in Nursing
at Creighton University in 2002 and a Masters of Science in Forensic Nursing in
2019. For the past decade, she has worked as a Forensic Nurse Examiner (FNE). She
currently manages the FNE team at the University of Colorado Hospital (UCH) in
Aurora, CO where she developed a robust FNE orientation program as well as
education and training for on-going FNE performance-based competencies,
clinical skills exemplars, and high-fidelity simulations. She has also created
a Strangulation Pathway at UCH that serves as a clinical practice guideline for
Diana Faugno MSN, RN, CPN, SANE-A,
SANE-P, FAAFS, DF-IAFN, DF-AFN is a forensic nurse consultant in Dallas,
Georgia and the founding president of the Academy of Forensic Nursing.
Kathy Bell MS, RN, DF-AFN joined the
Tulsa Police Department in 1994. She provides the day-to-day operations
management of the forensic nurse examiner programs. Bell is a forensic nurse,
performing examinations for victims of sexual assault, domestic violence, elder
abuse, and drug-endangered children. She is designated Distinguished Fellow and
Founding Board member of the Academy of Forensic Nursing.
Adewale, L. 2009. Anatomy and assessment of the pediatric
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Baldwin-Johnson, C., and T. Wiese. 2015. “Strangulation in
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Enforcement, Healthcare Providers, Advocates and Prosecutors. San Diego: Training
Institute on Strangulation Prevention.
Faugno, D., D. Warzak, G. Strack, M. A. Brooks, and C. Gwinn.
2013. Strangulation forensic examination: Best practice for health care
providers. Advanced Emergency Nursing. 35(4):314-327.
Jain, V., M. Ray, S. Singhi. 2001. Strangulation injury: A form
of child abuse. Indian Journal of Pediatrics. 68(6):571-572.
Training Institute on Strangulation Prevention. 2019. Pediatric
Strangulation. Retrieved from: https://www.strangulationtraininginstitute.com/pediatric